'It’s not an illness,' Fort Myers doc says of transgender patients

Dr. Craig Sweet, a specialist in reproductive medicine froze the ovary tissue of a patient who was suffering from endometriosis. This is first case in Southwest Florida.(Photo11: Andrew West/The News-Press)Buy Photo

Fort Myers endocrinologist Dr. Craig Sweet spoke with The News-Press about the progress of medical transitioning for transgender men and women, who he’s been treating for 30 years. The interview was lightly edited for clarity and length.

How has your practice evolved since you began treating transgender patients?

I have an unusual perspective because I have been doing it for so long, 30 years. I worked in an intersex disorder clinic during my medical school fellowship at the Medical College of Georgia (now Georgia Health Sciences University. That was in 1989.

“The stigmatism of the transgender population is slowly ebbing away,”

Craig Sweet, M.D.

Obviously a lot has changed. The rules were much more rigid then. When I was in residency, if a person wanted to transition they had to live the role for a year. Then they had to have surgery. Then hormonal treatment.

Now I need a letter from a skilled mental health professional evaluating the patient to initiate treatment. (Sweet works with certified transgender therapists Kathryn Lowery and Edith Sodova of I-BOS Counseling Center based in Fort Myers.)

The patient can transition to whatever level they would like. You could transition by lifestyle but not hormones. You could have a patient who lives the lifestyle and transitions hormonally but decides not to go through the surgical changes. And others who go full court press.

The stigma of the transgender population is slowly ebbing away, although I don’t think Washington has been that kind to the trans patient.

The other important change to note is that in the past there was a 10-to-1 ratio of male-to-female transitions. In 2017, out of 40 of my transgender patients, I had 25 transitioning from male to female and 15 from female to male.

So the ratio has radically changed. It’s closer to 50-50. I think it has to do with female empowerment, making women independent thinkers and actors.

Your patients had to be diagnosed with gender dysphoria, a mental illness, in order to be seen by you. Is it a mental illness?

“No. I don’t consider it an illness.”

Craig Sweet, M.D.

No. I don’t consider it an illness. I don’t think it belongs with psychiatric disorders like bipolar and depression. There is a push to take it out of the next DSM (the Diagnostic and Statistical Manual of Mental Disorders compiled by the American Psychiatric Association). (The World Health Organization declassified gender dysphoria as a mental illness in June 2018.)

Does hormone replacement therapy pose any risks for transgender patients?

We want people to transition, but I don’t want to hurt anyone along the way. Their blood can thicken, and that’s a clot risk. I recommend a baby aspirin a day to keep them safe.

“Their blood can thicken, and that’s a clot risk.”

Craig Sweet, M..D.

I get baseline labs. They are different for each gender. Women are easier because we are only dealing with one hormone, testosterone. I decide what kind.

All of my patients are on injections. There are creams and patches, but they are more expensive, and it’s harder for me to get the right levels in the right location. I decide the dose and frequency based on the patient’s age, goals and size. We treat, and then we monitor.

One of the concerns with female-to-male patients who keep their uterus is the potential risk for endometrial cancer or uterine cancer. Testosterone converts to estrogen in the body. If you can’t get your hysterectomy covered by insurance, I have to monitor the lining and biopsy it.

“There are numerous transition stories that ended in death from endometrial carcinoma.”

Craig Sweet, M.D.

There are numerous transition stories that ended in death from endometrial carcinoma. I’ve picked up pre-cancers on patients and can use them to get the hysterectomy covered. In general, it’s not covered by insurance.

How affordable is transitioning for your patients?

The trans population can be economically challenged. They may not be able to keep relationships or jobs. It’s important to be cognizant of that and not drag them into the office for silly reasons.

“I try not to complicate their lives.”

Craig Sweet, M.D.

We meet about twice a year. A few patients are so good at this that I can see them less often. I try not to complicate their lives.

The treatment for male to female is more complicated. I use bio identical or natural estrogen, and also Aldactone, a kind of water pill, that minimizes the effect of testosterone at the hair follicles.

These are adults. They may already have beards, so they need electrolysis to destroy the hair follicle.

Southwest Florida has a different socio economic layout. My trans patients don’t have a lot of disposable income, so they have to pick and choose what they spend their money on, which is why my taking care of these patient is sort of perfect. It is not a money making venture.

What is the youngest patient you have helped to transition?

The community wishes I would work with young children. Here are the issues. Older literature suggests adolescents will change their mind 20 percent of the time. Also, that children will change their mind 50 percent of the time.

“Some of the effects of hormone replacement therapy are not reversible.”

Craig Sweet, M.D.

Some of the effects of hormone replacement therapy are not reversible. The facial body hair, for example: once you develop male hair, you can’t flip it back. The hair loss and deepening of voice isn’t reversible, either.

So that kind of reversal rate for children to me is a little nerve wracking; I'm still trying to figure out how to do this without causing harm.

Do we need more practitioners for this population?

“It’s a joy to take care of so many of these patients because they are so much happier.”

Craig Sweet, M.D.

I really think these patients have tremendous difficulties finding good medical care. They get this crap on the Internet. Not cool. Part of my responsibility is to educate regional physicians how to do this.

It’s a joy to take care of so many of these patients because they are so much happier. They are in much better places now.